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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> j APPLICATION <br /> (For Non-ELtnsffC <br /> able, Revocable, and 5uspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in thejurisdictional areaof the San Joaquin Local Health District <br /> h Business Name (DBA)�h�ra " adnF/ �� U-,C�_ __ Address <br /> 4 Owner m, LJE49H _- Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 'T�S ��.�� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants+Name (Prince);� lfr Title T. Date <br /> Please check Applicable.Category (1-7)and Fill in the Required Information q} <br /> y• ..;. b .a.yr+' P <br /> 1. El PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W <br /> For July 1, June 30, 19 Disposal Sites -� <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 1Lr <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. �. <br /> Test Location Test Date/Time _ I <br /> 4. XSANiTATION PERMIT_ s` / 1 _ ! /,,`��, rf <br /> Job Address/Location ��� 37 �_ 4),F t tyt1� _ � eGe_ ' �``t�� <br /> Owner E Address o A!V � a�gna4FR�&1�C% <br /> ❑ SEPTIC TANK ❑ CESSPOOL i. ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT- <br /> PERMANENT © TEMPORARY ❑ NEW >CREPAIR OOTHER RC-D 4-),0Dff %Aitrf� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -dune 30, 19 4-1 i... <br /> Type Construction i Disposal Site <br /> No. of Units Eqiuipment Storage/Cleaning-Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 p <br /> Operator Name Where Certified <br /> Plant Location -- --- - <br /> Plant Capacity No. Units Servedi <br /> 7. ❑ LdUNDRY For July 1, -June 30, 19 i <br /> SIZE; I❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.-% -• - � <br /> � <br />' r <br /> ( <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I ordinances, state law les and reguI ions of a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER NIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juty 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE - EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION v. <br /> PLUS <br /> PENALTY <br /> F <br /> OTHER <br /> p <br /> OTHEfl __�- <br /> Received by Date Receipt No. - '- Permit No. � c -�:, Issuance Date Mailed } Delivered it <br /> i - APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9501 <br />